May 5, 2020

J15 Targeted Probe and Educate Status Update January 1, 2020 – March 31, 2020

Medical Review initiated the Targeted Probe and Educate (TPE) process on October 1, 2017 per CR10249. TPE probe edits were initiated for specific providers identified through data analysis demonstrating high risk for improper payment and previous probe and targeted reviews. Education has been offered to providers throughout and upon completion of Round 1 of the probe review.  Medical Review initiated 35 provider edits during the period of January 1, 2020 through March 31, 2020. Twenty-two providers progressed to Round 2 based on previous probe or targeted review results.

On March 13, 2020, Secretary Azar authorized waiver and modifications under §1135 of the Social Security Act retroactive to March 1, 2020. CGS has temporarily suspended TPE reviews. Our Medical Review and Provider Outreach and Education staff are available to conduct educational sessions and provide answers to questions to ensure providers understand regulatory guidelines to prevent improper payment.  Resources and Guidelines are listed throughout this article.

Results for all probe rounds are listed in the chart below. Additional charts provide results by round.

Results	Kentucky	Ohio
Probes Completed	28	31
Providers Compliant after Round Completion	13	11
Providers Non-compliant after Round Completion	15	20
Providers with Non-Responses to ADR’s for Round	8	11

This chart reflects Round 1 probes completed between January 1, 2020 and March 31, 2020:

Results	Kentucky	Ohio
Probes Completed	20	10
Providers Compliant after Round 2 Completion	6	2
Providers Non-compliant after Round 2 Completion	14	8
Providers with Non-Responses to ADR’s for Round 2	6	3

The results of the probes per strategy item are listed below:

Strategy: Emergency Room Visits

Results	Kentucky	Ohio
Probes Completed	1	1
Providers Compliant after Round 1 Completion	1	1
Providers Non-compliant after Round 1 Completion	0	0
Providers with Non-Responses to ADR’s for Round 1	0	0

Findings:

• Documentation did not meet level of service billed
  • Lack of comprehensive history
  • Lack of high decision making
• Documentation did not meet split shared guidelines

Strategy: Home Visits

Results	Kentucky	Ohio
Probes Completed	4	0
Providers Compliant after Round 1 Completion	0	0
Providers Non-compliant after Round 1 Completion	4	0
Providers with Non-Responses to ADR’s for Round 1	1	0

Findings:

• Documentation did not support medical necessity
  • Patients with chronic stable conditions seen on monthly basis
• Documentation did not support key components for level of service billed per E&M guidelines

Strategy: Hospital Visits

Results	Kentucky	Ohio
Probes Completed	3	0
Providers Compliant after Round 1 Completion	1	0
Providers Non-compliant after Round 1 Completion	2	0
Providers with Non-Responses to ADR’s for Round 1	2	0

Findings:

• Documentation did not support key components for level of service billed per E&M Guidelines
• Documentation did not support split shared guidelines
• Late signature and addendum issues after the ADR letter was sent
• Documentation submitted late (after 45 days)
• Billing Errors
  • Documentation for incorrect date of service
  • Documentation billed for wrong provider

Strategy: Nursing Facility

Results	Kentucky	Ohio
Probes Completed	5	3
Providers Compliant after Round 1 Completion	1	0
Providers Non-compliant after Round 1 Completion	4	3
Providers with Non-Responses to ADR’s for Round 1	1	0

Findings:

• Documentation did not support medical necessity
  • Patients with chronic stable conditions seen on monthly basis
• Documentation did not support key components for level of service billed per E&M Guidelines
• Illegible documentation received

Strategy: Office Visits

Results	Kentucky	Ohio
Probes Completed	4	1
Providers Compliant after Round 1 Completion	2	1
Providers Non-compliant after Round 1 Completion	2	0
Providers with Non-Responses to ADR’s for Round 1	0	0

Findings:

• Documentation did not support medical necessity
• Documentation did not support medical necessity of visit frequency
• Documentation did not support key components for level of service billed per E&M Guidelines
• Documentation did not support a separately identifiable service above and beyond procedures for modifier 25 

Strategy: Physical & Occupational Therapy

Results	Kentucky	Ohio
Probes Completed	4	1
Providers Compliant after Round 1 Completion	2	1
Providers Non-compliant after Round 1 Completion	2	0
Providers with Non-Responses to ADR’s for Round 1	0	0

Findings:

• Documentation lacked objective measurements and  progress towards goals on the daily note
• Documentation lacked objective goals on evaluation/re-evaluation
• Signature issues:
  • Re-certifications signed after the 30 day limit with no attestation from signing provider
  • Co-signature of PT with PT assistant initiated on initial and re-certifications
• Incomplete documentation submitted

Strategy: Psychiatric Services

Results	Kentucky	Ohio
Probes Completed	1	5
Providers Compliant after Round 1 Completion	1	0
Providers Non-compliant after Round 1 Completion	0	5
Providers with Non-Responses to ADR’s for Round 1	0	3

Findings:

• Documentation did not support prognosis, progress or treatment plan
• Documentation did not support medical necessity
• Documentation did not record and/or support time spent in sessions
• Illegible documentation received

This chart reflects Round 2 probes completed between January 1, 2020 and March 31, 2020:

Results	Kentucky	Ohio
Probes Completed	6	19
Providers Compliant after Round 2 Completion	5	8
Providers Non-compliant after Round 2 Completion	1	11
Providers with Non-Responses to ADR’s for Round 2	2	7

Strategy: Ambulance

Results	Kentucky	Ohio
Probes Completed	0	1
Providers Compliant after Round 2 Completion	0	0
Providers Non-compliant after Round 2 Completion	0	1
Providers with Non-Responses to ADR’s for Round 2	0	1

Findings:

• Documentation did not support that beneficiary could not be transported by any other means.
• Conditions listed on Provider Certification Statement (PCS) and/or in the transport note do not support medical necessity of the transport.
• PCS forms were not signed by the beneficiary’s primary care physician and were instead signed by ancillary staff for scheduled repetitive transports.

Strategy: Home Visits

Results	Kentucky	Ohio
Probes Completed	0	1
Providers Compliant after Round 2 Completion	0	1
Providers Non-compliant after Round 2 Completion	0	0
Providers with Non-Responses to ADR’s for Round 2	0	0

Findings:

• Documentation did not support medical necessity
  • Patients with chronic stable conditions seen on monthly basis
• Documentation did not support key components for level of service billed per E&M Guidelines

Strategy: Hospital Visits

Results	Kentucky	Ohio
Probes Completed	1	0
Providers Compliant after Round 2 Completion	1	0
Providers Non-compliant after Round 2 Completion	0	0
Providers with Non-Responses to ADR’s for Round 2	1	0

Findings:

• Documentation did not support key components for level of service billed per E&M Guidelines
• Documentation did not support split shared guidelines
• Late signature and addendum issues after the ADR letter was sent
• Documentation submitted late (after 45 days)
• Billing Errors
  • Documentation for incorrect date of service
  • Documentation billed for wrong provider

Strategy Item: Physical & Occupational Therapy

Results	Kentucky	Ohio
Probes Completed	5	16
Providers Compliant after Round 2 Completion	4	6
Providers Non-compliant after Round 2 Completion	1	10
Providers with Non-Responses to ADR’s for Round 2	1	5

Findings:

• Documentation lacked objective measurements and  progress towards goals on daily notes
• Documentation lacked objective goals on the certification/re-certification
• Signature issues:
  • Re-certifications signed after the 30 day limit with no attestation from signing provider
  • Co-signature of PT with PT assistant initiated on initial and recertifications
• Incomplete documentation submitted

Strategy: Psychiatric Services

Results	Kentucky	Ohio
Probes Completed	0	1
Providers Compliant after Round 2 Completion	0	1
Providers Non-compliant after Round 2 Completion	0	0
Providers with Non-Responses to ADR’s for Round 2	0	1

Findings:

• Documentation did not support prognosis, progress or treatment plan
• Documentation did not support medical necessity
• Documentation did not record  and/or support time spent in sessions
• Illegible documentation received

This chart reflects Round 3 probes completed between January 1, 2019 and March 31, 2019:

Results	Kentucky	Ohio
Probes Completed	2	2
Providers Compliant after Round 3 Completion	2	1
Providers Non-compliant after Round 3Completion	0	1
Providers with Non-Responses to ADR’s for Round 3	0	1

Strategy: Ambulance

Results	Kentucky	Ohio
Probes Completed	0	1
Providers Compliant after Round 3 Completion	0	1
Providers Non-compliant after Round 3 Completion	0	0
Providers with Non-Responses to ADR’s for Round 3	0	0

Findings:

• Documentation did not support that beneficiary could not be transported by any other means.
• Conditions listed on Provider Certification Statement (PCS) and/or in the transport note do not support medical necessity of the transport.
• PCS forms were not signed by the beneficiary’s primary care physician and were instead signed by ancillary staff for scheduled repetitive transports

Strategy: Hospital Visits

Results	Kentucky	Ohio
Probes Completed	1	0
Providers Compliant after Round 3 Completion	1	0
Providers Non-compliant after Round 3 Completion	0	0
Providers with Non-Responses to ADR’s for Round 3	0	0

Findings:

• Documentation did not support key components for level of service billed per E&M Guidelines
• Documentation did not support split shared guidelines
• Late signature and addendum issues after the ADR letter was sent
• Documentation submitted late (after 45 days)
• Billing Errors
  • Documentation for incorrect date of service
  • Documentation billed for wrong provider

Strategy: Nursing Facility Visits

Results	Kentucky	Ohio
Probes Completed	1	0
Providers Compliant after Round 3 Completion	1	0
Providers Non-compliant after Round 3 Completion	0	0
Providers with Non-Responses to ADR’s for Round 3	0	0

Findings:

• Documentation did not support medical necessity
  • Patients with chronic stable conditions seen on monthly basis
• Documentation did not support key components for level of service billed per E&M Guidelines
• Illegible documentation received

Strategy: Office Visits

Results	Kentucky	Ohio
Probes Completed	0	1
Providers Compliant after Round 3 Completion	0	0
Providers Non-compliant after Round 3 Completion	0	1
Providers with Non-Responses to ADR’s for Round 3	0	1

Findings:

• Documentation did not support medical necessity
• Documentation did not support medical necessity of visit frequency
• Documentation did not support key components for level of service billed per E&M Guidelines
• Documentation did not support a separately identifiable service above and beyond procedures for modifier 25 

Resources:

How to Prevent Denials: 

• Documentation did not meet key components of the E/M service billed
  • Documentation Guidelines for Evaluation and Management Services
  • Fact sheets
• Split shared not properly documented
  • Split shared visits
  • § Pub. 100-02, Chapter 15 §§§ 60.1; 60.2; 60.3
  • § Pub. 100-04, Chapter 12, §30.6.1B
• Medical necessity was not documented appropriately
  • SSA 1862(a)(1)(A)
• Nursing facility visits:
  • Pub 100-4, Chapter 12 §30.6.13
  • MLN Matters MM4246: Nursing Facility Services (Codes 99304-99318)
  • Subsequent Nursing Facility Care (CPT Codes 99307-99310): Claim Submission and Documentation
  • Reporting Federally Mandated Visits
  • § 483.40 42 CFR Ch. IV
• Service did not meet modifier 25 criteria
  • Pub 100-04, Chapter 12, Section 40.1.8
  • Pub 100-04, Chapter 12, Bundled services 20.3
  • Pub 100-04, Chapter 12, Modifier 25 30.6.6 B
  • Pub 100-04, Chapter 12, Global surgery package 40.1; 40.2
  • Modifier 25 articles:
    • Modifier 25
    • Modifier-25 Use with "XXX" Surgery Codes
• No documentation was received (non-response)
  • SSA 1833 (e)
• Outpatient Physical and Occupational Services
  • CGS PT/OT Fact Sheet
  • CGS PT/OT Article with Associated Links to Additional Resources
• Outpatient  Psychiatry and Psychology Services
  • CGS Psychotherapy Fact Sheet
  • CGS LCD L34353: Outpatient Psychiatry and Psychology Services
• Ambulance Services
  • CGS Ambulance Fact Sheet
  • PUB 100-02 Ch 10 Ambulance Services
  • PUB 100-04 Ch 15 Ambulance
  • CFR 410.40

Next Steps:

Providers found to be non-compliant at the completion of Round 1 will advance to Round 2 and those found to be non-compliant at the completion of Round 2 will advance to Round 3 of TPE at least 45 days after completion of the post probe educational session. Providers do not have to be identified for TPE to request education. Part B Providers may submit TPE questions or request education via the Part B TPE email box (Please include your Provider Number in the subject of the email):

• J15BprobeandEducation@cgsadmin.com

CGS encourages providers to request education and conduct self-monitoring based on our posted Medical Review activity log and by using tools such as Comparative Billing Reports (CBRs) offered through our web portal.

• Comparative Billing Reports (CBRs) are Now Available through myCGS!

To learn more about the Targeted Probe & Education process, please refer to the following links:

• Targeted Probe & Educate (TPE)
• Video Education
• Targeted Probe and Educate (TPE) – Centers for Medicare & Medicaid Services